Conservative surgical management of subungual (matrix derived) melanoma: Report of seven cases and literature review

Department of Dermatology, Claude Bernard University, Hôpitaux de Lyon, Centre Hopitalier Lyon Sud, 69495 Pierre Bénite Cedex, France.
British Journal of Dermatology (Impact Factor: 4.28). 08/2011; 165(4):852-8. DOI: 10.1111/j.1365-2133.2011.10477.x
Source: PubMed


Subungual melanoma (SUM) is a rare entity, comprising approximately 0·7-3·5% of all melanoma subtypes. SUM histopathologically belongs to the acral lentiginous pathological subtype of malignant melanoma. Its diagnosis is helped by dermoscopy but pathological examination of doubtful cases is required. Classical management of SUM is based on radical surgery, namely distal phalanx amputation. Conservative treatment with nonamputative wide excision of the nail unit followed by a skin graft has been insufficiently reported in the medical literature even though it is performed in many centres.
To report a series of patients with in situ or minimally invasive SUM treated by conservative surgery, to investigate the postoperative evolution and to evaluate the outcome with a review of the literature.
We performed a retrospective extraction study from our melanoma register of all patients with in situ and minimally invasive SUM treated with conservative surgery in the University Hospital Department of Dermatology, Lyon, France from 2004 to 2009. The patient demographics, disease presentation, delay to diagnosis, histopathology and postoperative evolution were reviewed.
Seven cases of SUM treated as such were identified in our melanoma database. All cases had a clinical presentation of melanonychia striata. The mean delay to diagnosis was 2years. Surgical excision of the entire nail unit with a 5-10mm safety margin without bone resection followed by full-thickness skin graft taken from the arm was performed in all cases. No recurrence was observed with a mean follow-up of 45months. Functional results were found satisfactory by all patients and their referring physicians. Sixty-two other cases have been found in the literature and are also discussed.
Conservative surgical management in patients with in situ or minimally invasive SUM is a procedure with good cosmetic and functional outcome and, in our cases as well as in the literature, the prognosis is not changed.

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    • "Czerniak podpaznokciowy (subungual melanoma -SM) stanowi rzadką odmianę czerniaka -0,7-3,5% wszystkich czerniaków [28]. Jednak ze względu na brak wczesnej reakcji pacjenta oraz jego późną wykrywalność, zwykle w fazie znacznego zaawansowania klinicznego, czerniak podpaznokciowy należy do nowotworów o złym rokowaniu . "
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    ABSTRACT: Subungual melanoma is a rare, but one of the diagnostically most difficult variants of melanoma. Unfortunately, due to its late detection, lack of an early reaction from the patient and diagnosis in advanced stages, subungual melanoma is deemed as a prognostically unfavorable variant of this malignancy. Diagnosis of subungual melanoma is very difficult to establish merely on the basis of clinical examination due to the resemblance of subungual hematoma to melanocytic nevus, fungal or bacterial infections. Dermoscopy seems to be the ideal diagnostic tool in the differential diagnosis of this life-threatening disease. Aims. To describe the basic aspects of dermoscopy of subungual melanoma and other conditions involving the nails. Methods. Review of medical database PubMed for the literature of the last 10 years on the dermoscopic patterns of subungual melanoma and other subungual diseases. Results. We collate the fundamental rules of performing dermoscopy in subungual melanoma, as well as basic dermoscopic features and diagnostic algorithms of selected subungual lesions requiring differentiation from melanoma. Conclusions. Dermoscopy is a safe, easily repeatable diagnostic method, and the knowledge of basic dermoscopic patterns of developing melanoma in subungual localization, along with the differential diagnosis of other diseases within the nail plate, will help not only dermatologists, but also the professionals of other specialties, such as surgeons, oncologists, orthopedists, and also general practitioners.
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